BILLING NEWS

MCS Implementation of the Restructured Clinical Lab Fee Schedule

May 26, 2017

The "Protecting Access to Medicare Act (PAMA) of 2014," added a provision that requires extensive revisions to the payment and coverage methodologies for clinical laboratory tests paid under the clinical laboratory fee schedule (CLFS). The final rule set forth new policies for how CMS sets rates for tests on the CLFS and is effective for dates of service on and after January 1, 2018. Beginning on January 1, 2017, applicable laboratories were required to submit data to CMS which describes negotiated payment rates with private payers for any corresponding volumes of tests on the CLFS. In general, with certain designated exceptions, the payment amount for a test on the CLFS furnished on or after January 1, 2018, will be equal to the weighted median of private payer rates determined for the test, based on data collected from laboratories during a specified data collection period. In addition, a subset of tests on the CLFS, advanced diagnostic laboratory tests (ADLTs), will have different data, reporting, and payment policies associated with them. Change Request (CR) 10057 instructs Medicare's Multi-Carrier System (MCS) maintainer to incorporate into the shared system, the revised Clinical Lab Fee Schedule (CLFS) containing the National fee schedule rates.